Intravenous acyclovir treatment for primary genital herpes

A Comparative Study of Intralesional Acyclovir vs Immunotherapy for Treatment of Viral Warts

BACKGROUND

Viral warts are caused by human papillomavirus (HPV), are difficult to treat with conventional modalities, and are cosmetically disfiguring; hence, immunomodulators are being used. The viral origin of warts suggests the antiviral drug acyclovir as a potential therapeutic option. The current study compares the effect of intralesional acyclovir (nucleoside analogue) and intralesional purified protein derivative (PPD) (immunotherapy) in treating various viral warts.

METHODOLOGY

Prospective observational comparative study was conducted to determine the efficacy of acyclovir, and PPD administered via the intralesional route in patients with viral warts. The study population was categorized into two groups. One group received intralesional acyclovir, and the other received intralesional PPD. Patients were followed-up with for three months. Outcomes considered in our study were recovery (complete, partial, and no recovery) and side effects like pain, burning sensation, and desquamation. Statistical analysis was carried out by coguide software.

RESULTS

In our study total of 40 participants, 20 in each group were included. 25 and 15 were of age <30, and ≥ 30, respectively, while 20 were males, and 20 females. Our study reported 60%, and 30% of complete recovery with intralesional acyclovir treatment and intralesional PPD treatment, respectively, in the twelfth week. However, p-value > 0.05 represented no significance between groups. 90% in the acyclovir-treated group presented with pain, and 100% presented with burning sensation, while in the case of PPD-treated group, 60% presented no side effects and the rest 40% showed pain.

CONCLUSIONS

Intralesional acyclovir is more effective in treating viral warts than PPD. The focus is to be laid on anticipated side effects.

[Management of pregnant women with first episode of genital herpes. Guidelines for clinical practice from the French college of gynecologists and obstetricians (CNGOF)]

OBJECTIVE

To provide guidelines for the management of first episode genital herpes during pregnancy and in the immediate postpartum period.

METHODS

MedLine and Cochrane Library databases search and review of the main foreign guidelines.

RESULTS

In case of first episode genital herpes during pregnancy, antiviral treatment with acyclovir (200mg 5 times daily) or valacyclovir (1000mg twice daily) for 5 to 10 days is recommended (grade C). The patient should be tested for HIV if not previously done (grade B). Daily suppressive antiviral treatment with acyclovir (400mg 3 times daily) or valacyclovir (500mg twice daily) is recommended from 36 weeks for women who have had a first episode genital herpes during pregnancy (grade B). A cesarean section should be performed in case of suspicion of first episode genital herpes at the onset of labor (grade B) or premature rupture of the membranes at term (professional consensus), or in case of first episode genital herpes less than 6 weeks before delivery (professional consensus). In the event of first episode genital herpes highlighted in the postpartum period, the neonatologist should be informed (professional consensus). The patient may be treated according the scheme described above.

CONCLUSION

A cesarean section should be performed in case of first episode genital herpes less than 6 weeks before delivery.

Interventions for men and women with their first episode of genital herpes

BACKGROUND

Genital herpes is incurable, and is caused by the herpes simplex virus (HSV). First-episode genital herpes is the first clinical presentation of herpes that a person experiences. Current treatment is based around viral suppression in order to decrease the length and severity of the episode.

OBJECTIVES

To determine the effectiveness and safety of the different existing treatments for first-episode genital herpes on the duration of symptoms and time to recurrence.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (from inception to April 2016), MEDLINE (from inception to April 2016), the Specialised Register of the Cochrane Sexually Transmitted Infections Review Group (from inception to April 2016), EMBASE (from inception to April 2016), PsycINFO (from inception to April 2016), CINAHL (from inception to April 2016), LILACS (from inception to April 2016), AMED (from inception to April 2016), and the Alternative Medicines Specialised Register (from inception to April 2016). We handsearched a number of relevant journals, searched reference lists of all included studies, databases of ongoing trials, and other Internet databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on participants with first-episode genital herpes. We excluded vaccination trials, and trials in which the primary objective assessed a complication of HSV infection.

DATA COLLECTION AND ANALYSIS

All studies written in English were independently assessed by at least two review authors for inclusion, risk of bias for each trial, and to extract data. Studies requiring translation were assessed for inclusion, trial quality, and data extraction by external translators.

MAIN RESULTS

We included 26 trials with 2084 participants analysed. Most of the studies were conducted in the United Kingdom (UK) and United States (US), and involved men and women experiencing their first episode of genital herpes, with the exception of three studies which included only women. We rated the majority of these studies as having an unclear risk of bias; largely due to lack of information supplied in the publications, and due to the age of the trials. This review found low quality evidence from two studies of oral acyclovir, when compared to placebo, reduced the duration of symptoms in individuals undergoing their first episode of genital herpes (mean difference (MD) -3.22, 95% confidence interval (CI) -5.91 to -0.54; I(2) = 52%). In two studies (112 participants), intravenous acyclovir decreased the median number of days that patients with first-episode herpes suffered symptoms. Oral valaciclovir (converted to acyclovir) also showed a similar length of symptom duration when compared to acyclovir in two studies.There is currently no evidence that topical acyclovir reduces symptoms (MD -0.61 days, 95% CI -2.16 to 0.95; 3 RCTs, 195 participants, I(2) statistic = 56%). There is also no current evidence that the topical treatments of cicloxolone cream, carbenoxolone sodium cream, adenosine arabinoside, idoxuridine in dimethyl sulfoxide, when compared to placebo reduced the duration of symptoms in people undergoing their first episode of herpes.Two studies reported no evidence of a reduction in the number of median days to recurrence following treatment with oral acyclovir versus placebo. Adverse events were generally poorly reported by all of the included studies and we were unable to quantitatively analyse this outcome. For those taking acyclovir, there were no serious adverse events; the most common adverse events reported for oral acyclovir were coryza, dizziness, tiredness, diarrhoea and renal colic. For intravenous acyclovir these were phlebitis, nausea and abnormal liver function tests and for topical acyclovir there was pain with the topical application.Those undergoing interferon treatment had significantly more adverse events compared to those taking placebo.

AUTHORS' CONCLUSIONS

There is low quality evidence from this review that oral acyclovir reduced the duration of symptoms for genital herpes. However, there is low quality evidence which did not show that topical antivirals reduced symptom duration for patients undergoing their first episode of genital herpes. This review was limited by the inclusion of skewed data, resulting in few trials that we were able to meta-analyse.

A sustained release dosage form of acyclovir for buccal application: An experimental study in dogs

Acyclovir is an antiviral agent and it has been particularly used for the treatment of herpes simplex infections. The treatment of infection in the oral cavity is often difficult, because of insufficient drug concentration in saliva when acyclovir is administered via the oral route in conventional tablet form for systemic uptake. Therefore, it was aimed to prepare a tablet for buccal administration and to investigate its effectiveness by performing in vitro and in vivo experiments.The solubility (1.559-4.584) and octanol/water partition coefficients ( - 2.176 to - 1.625) of the acyclovir were investigated at different pH conditions. A series of tablet formulations were prepared for buccal application and their dissolution properties were determined in artificial saliva medium. The effect of tablet ingredients on the release rate and mucoadhesion force was investigated. The dissolution properties of commercially available acyclovir tablets were also determined in the artificial gastric juice. Franz type diffusion cells were used to determine acyclovir penetration through buccal mucosa from prepared buccal tablets. Selected buccal tablets, commercial tablets and intravenous acyclovir solutions were administered to mongrel dogs and drug levels in the blood determined by HPLC.A pharmacokinetic model for buccal application was also developed and blood concentrations were calculated theoretically and compared with the experimental results. Prepared buccal tablets were found to be effective for the treatment of viral infections locally within the oral cavity and also for systemic treatment.

Patient satisfaction with care for genital herpes: insights from a global survey

OBJECTIVE

To describe patient experiences and views regarding genital herpes management.

METHODS

Between February 2002 and January 2003, subjects with genital herpes were recruited via the International Herpes Alliance website and through banners on additional sites. Surveys were available in English, French, Spanish, Italian, and German and assessed views on access to care, diagnosis, related emotional experiences, educational resources, counselling, pharmacotherapy, and satisfaction with care.

RESULTS

2075 patient responses from 78 countries were analysed. 49% reported their diagnosis was by culture (or other direct detection) and 9% by antibody test, while 34% reported they had been diagnosed by examination alone. 65% used a prescription antiviral therapy, 18% a topical antiviral therapy, and 17% an alternative therapy. Of 901 subjects who reported on frequency of antiviral use, only 30% reported a frequency consistent with a suppressive regimen while 59% of respondents said they would be likely to take daily therapy if it reduced the frequency of outbreaks. Patient satisfaction with management of physical symptoms was independently associated with duration of initial visit >or=15 minutes (adjusted odds ratio (OR) = 4.52), receiving a prescription (adj OR = 2.34) and receipt of a brochure/fact sheet (adj OR = 2.14). Satisfaction with attention to emotional issues also correlated with the first two of these factors.

CONCLUSIONS

Genital herpes management may be improved by including the use of confirmatory laboratory testing, employing a full range of antiviral therapy options, providing educational materials, and committing more time to counselling at the initial visit.

Current treatment options to prevent perinatal transmission of herpes simplex virus

Neonatal herpes is a potentially devastating consequence of perinatal transmission of the herpes simplex virus (HSV), with significant morbidity and mortality. Treatment options are available, but must begin early in disease with manifestations that are often protean. Thus, preventive measures need to be optimised. Antiviral suppression in late pregnancy of women with a history of recurrent genital herpes will decrease symptomatic recurrence at delivery and appears to reduce caesarian section rates. However, primary HSV Type 2 and primary HSV Type 1 episodes have the highest neonatal transmission rates and thus, effective prevention may require the identification and suppression of the discordant partner. Significant experience has been gained with the use of acyclovir in pregnancy and it is recommended for both episodic and suppressive therapy in pregnant women. Its use has been demonstrated to be cost-effective in suppressive therapy, although issues regarding compliance and the potential for neonatal neutropenia need to be addressed. The more conveniently dosed prodrugs valacyclovir and famciclovir are being evaluated for use in pregnancy.

Treatment of mucocutaneous presentations of herpes simplex virus infections

Infections by herpes simplex virus (HSV) types I and II are diverse and quite frequent. After primary infection, the virus establishes a life-long latency in the sensory ganglia and recrudescences may occur at an unpredictable rate. Recurrent labial and genital herpes infections represent the majority of clinical manifestations of HSV infections. Their management is currently well established using evidence-based medicine data. Primary labial herpes is generally not treated with antivirals in otherwise healthy children, although intravenous aciclovir may be offered in severe primary infections, particularly in the immunocompromised patient. The decision whether or not to treat recurrent labial herpes should be evaluated individually and depends on the frequency and severity of relapses, the impairment of the quality of life, and the cost of therapy. Patients with mild disease may benefit from topical therapy, and those with severe and frequent recurrences may be considered for intermittent or long-term oral antiviral therapy. Primary genital herpes is treated with oral or intravenous antivirals, depending on the severity of the infection and associated symptoms. Recurrent genital herpes can be managed with episodic short courses of oral antivirals in patients whose recurrences are moderate to severe and rare, and have a clear prodrome. Patients with >5 episodes/year, severe recurrences or unrecognisable prodromes may be best managed with long-term suppressive antiviral prophylaxis. HSV is also responsible for a variety of other clinical manifestations, including herpetic whitlow, neonatal infection, disseminated and atypical cutaneous infections, traumatic herpes, eczema herpeticum, and HSV-associated erythema multiforme. HSV infection may also represent a complication following cosmetic procedures of the oro-facial region, surgical and dental interventions, sun exposure and burns. Precise treatment guidelines for these HSV infections are not firmly established.

Current recommendations for the treatment of genital herpes

The incidence of genital herpes continues to increase in epidemic-like fashion. Aciclovir (acyclovir) has been the original gold standard of therapy. The recent addition of famciclovir and valaciclovir as antiherpes drugs has improved convenience as well as the efficacy of treatment. Although aciclovir remains a widely prescribed and reliable drug, its administration schedule falls short of the ease of usage that the newer nucleoside analogues offer, for both episodic and suppressive therapy. Suppression of symptomatic disease and asymptomatic shedding from the genitalia have both become popular approaches, if not the primary targets of antiviral therapy. Knowing that asymptomatic disease leads to most cases of transmission strongly suggests that suppression with antiviral agents could reduce transmission risk in discordant couples. Unfortunately, the role for antivirals in reducing transmission remains to be proven in clinical trials. Neonatal herpes is now successfully treated using aciclovir. Current randomised clinical trials are examining aciclovir and valaciclovir administration, as well as safety and efficacy for post-acute suppressive therapy. Prevention of recurrences in pregnancy is also a topic under investigation, with a view to reducing the medical need for Cesarean section, or alternatively (and far less likely to be accomplished) to protect the neonate. Although resistance is largely limited to the immunocompromised and a change in resistance patterns is not expected, several drugs are available for the treatment of aciclovir-resistant strains of herpes simplex. Foscarnet is the main alternative with proven efficacy in this setting. Unfortunately, administration of foscarnet requires intravenous therapy, although a single anecdote of topical foscarnet efficacy in this setting has been published. Alternatives include cidofovir gel, which is not commercially available but can be formulated locally from the intravenous preparation. Less effective alternatives include trifluridine and interferon. Future possibilities for treatment of genital herpes include a microparticle-based controlled-release formulation of aciclovir and resiquimod (VML-600; R-848). The search for an effective therapeutic vaccine for genital herpes has not been successful to date, although a live virus glycoprotein H-deficient (DISC) vaccine is currently in clinical trials. Recent data suggest that seronegative women are protected (albeit, not fully) by a glycoprotein D recombinant vaccine with adjuvant. Despite the established safety and convenience of current treatment options, better suppressive options and topical treatment options are much needed. Studies using existing agents as potential tools to avoid Cesarean section, or transmission to neonate or partner are ongoing. Both vaccines and antivirals may eventually play a role in prevention of infection.

A risk-benefit evaluation of aciclovir for the treatment and prophylaxis of herpes simplex virus infections

The objective of this article is to review and evaluate risks and benefits associated with the use of acyclovir in the treatment and prophylaxis of common manifestations of herpes simplex virus (HSV) infections in immunocompetent and immunocompromised patients. Information was found through a MEDLINE search using keywords: herpes simplex virus, genital herpes, herpes labialis, acyclovir and acyclovir. Selected articles were randomised, double-blind, placebo-controlled, clinical trials. 30 such trials involving 3364 persons were evaluated. All articles were reviewed by the authors and the data were extracted and summarised. In both immunocompetent and immunocompromised hosts, acyclovir therapy demonstrated a high degree of clinical efficacy. None of the studies reported statistically significant differences between acyclovir and placebo for mild or major adverse events. This evaluation found that acyclovir is both effective and well tolerated for treatment and prophylaxis of genital, oral and mucocutaneous HSV infections in immunocompetent and immunocompromised patients. In most clinical scenarios. the benefit of acyclovir exceeded any risks by a comfortable margin. The availability of acyclovir as a generic preparation further improves the benefit to cost ratio.

The Value of Antivirals in Genital Herpes

Although aciclovir has been the most extensively used nucleoside analogue for the treatment of genital herpes, its poor bioavailability, frequent dosing (five times daily), and the short intracellular half-life of the active triphosphate (≤1–2 h) has led to the development of a new generation of agents. The prodrug valaciclovir (active agent aciclovir), and famciclovir (active agent penciclovir) have improved pharmacokinetics compared with aciclovir. Compared with oral aciclovir, valaciclovir yields aciclovir with three-fivefold higher serum levels and the oral prodrug famciclovir yields even higher serum levels of penciclovir. The active agent, penciclovir triphosphate, has a prolonged intracellular half-life in vitro [10 h for cells infected with herpes simplex virus type 1 (HSV-1) and 20 h for HSV-2-infected cells]. Evidence also suggests that famciclovir may have an effect on the establishment of latency in primary infection, thus reducing the risk of subsequent recurrent disease. Ongoing clinical trials are underway exploring this possibility. For patients with frequent recurrences of genital herpes, or patients psychologically disabled by the condition, twice-daily antiviral therapy offers the most effective reduction in the frequency of clinical recurrence. Twice-daily therapy also has the advantage that patients are at less risk of asymptomatic breakthrough and the potential risk of transmission if they forget to take one dose.

Genital herpes: natural history and treatment of acute episodes

Genital herpes is a common, distressing infection whose incidence has been underestimated. Recent serological surveys, employing type-specific antibody assays, show a rising prevalence of previous herpes simplex virus (HSV) type 2 infections in post-adolescent populations in developed countries; many of these infections have been asymptomatic. In some geographical locations, HSV-1 infections are a common cause of first episodes. They may occur in stable, monogamous relationships and are less likely to recur than genital infections caused by HSV-2. The clinical features of first episode genital herpes show marked individual variation in severity; they tend to be more severe in women than in men. Local and distant complications are common in immunocompetent individuals and may be life-threatening in those who are immunocompromised. The psychological and social consequences which result from the life-long infection and its risks of transmission to new sexual partners often prove more disabling to affected individuals than do the milder physical symptoms associated with recurrent episodes. Counselling, support, and patient education are essential components of management. Acyclovir is clearly established as the first choice therapy in both first and recurrent episodes of genital herpes. This drug has potent antiviral effect and provides significant clinical benefit in first episodes. Systemic therapy for initial episodes does not prevent either the establishment of latency or the development of future recurrences even when used in high or prolonged dosage. Episodic treatment of recurrences, with either oral or topical acyclovir, requires early patient initiation of therapy to provide significant clinical benefit.

Systemic antiviral drugs used in ophthalmology

Over the past two decades, the recognition of viral enzymes and proteins that can serve as molecular targets of drugs has revolutionized the treatment of viral infections. Beginning with acyclovir, a number of systemically administered agents which are both relatively safe and effective for the treatment of herpetic infections and human immunodeficiency virus (HIV) infections have become widely available. Because of increased numbers of herpes virus infections, as well as the rising epidemic of HIV infections, the ophthalmologist is, more likely than ever before to be involved in the treatment of severe and frequent ocular infections caused by herpes viruses. In addition, the acute retinal necrosis (ARN) syndrome has been demonstrated to be caused by herpes viruses and a once rare retinal infection caused by cytomegalovirus is common in patients with the acquired immunodeficiency syndrome (AIDS). In this article, four systemic antiviral drugs (Vidarabine, Acyclovir, Ganciclovir, and Foscarnet) that have demonstrated usefulness in the treatment of ophthalmic disease are reviewed in detail with regard to their mechanisms, applications, effectiveness, and side effects.

Antiviral therapy: current concepts and practices

Drugs capable of inhibiting viruses in vitro were described in the 1950s, but real progress was not made until the 1970s, when agents capable of inhibiting virus-specific enzymes were first identified. The last decade has seen rapid progress in both our understanding of antiviral therapy and the number of antiviral agents on the market. Amantadine and ribavirin are available for treatment of viral respiratory infections. Vidarabine, acyclovir, ganciclovir, and foscarnet are used for systemic treatment of herpesvirus infections, while ophthalmic preparations of idoxuridine, trifluorothymidine, and vidarabine are available for herpes keratitis. For treatment of human immunodeficiency virus infections, zidovudine and didanosine are used. Immunomodulators, such as interferons and colony-stimulating factors, and immunoglobulins are being used increasingly for viral illnesses. While resistance to antiviral drugs has been seen, especially among AIDS patients, it has not become widespread and is being intensely studied. Increasingly, combinations of agents are being used: to achieve synergistic inhibition of viruses, to delay or prevent resistance, and to decrease dosages of toxic drugs. New approaches, such as liposomes carrying antiviral drugs and computer-aided drug design, are exciting and promising prospects for the future.

Management of genital herpes simplex infection

Herpes simplex infection of the genitals is a common condition, more often due to herpes simplex virus (HSV) type 2 than to type 1 virus. There is a severe first attack followed by mild recurrences which are more common and more frequent after HSV-2 than after HSV-1 genital infection. Clinical features with prodrome, vesicles and erosions may be characteristic allowing rapid clinical diagnosis. When possible laboratory confirmation should be attempted. General management includes simple hygiene, avoidance of sexual transmission, use of condoms, and notifying partners. Oral acyclovir (Zovirax, Wellcome) is the drug of choice for initial attacks and should be considered for all women with this diagnosis. Intravenous acyclovir may be used for very severe attacks. Men with initial attacks may be treated with oral acyclovir but mild disease affecting only skin may be treated with 5% acyclovir cream. Recurrences are short so acyclovir has less effect. Frequent recurrences can be troublesome and may be suppressed by continuous oral acyclovir, or individual attacks may be aborted with intermittent therapy. Various systemic complications may occur; an important but rare problem is primary herpes in late pregnancy. Acyclovir is effective in the treatment of the troublesome herpes simplex disease associated with human immunodeficiency infection. Acyclovir is one of the more expensive treatments for sexually transmitted diseases. At present in many countries costs are being examined, and application of the principles outlined here should help to minimize cost and maximize care.

Experimental keratitis in rabbits by human HSV-1 variants: prevention and treatment

The efficacy of different therapies and vaccine preparations was assessed for treating or preventing herpetic ocular keratitis induced by experimental inoculation in rabbits with two HSV-1 variants that display different pathogenetic potential. Early administration of acyclovir (ACV) promoted fast healing and prevented neurologic involvements: alpha-interferon (alpha-IFN) was less efficient than ACV; combined therapy with both drugs increased the antiviral effects. In an attempt to prevent the disease, rabbits were vaccinated with a slightly pathogenic HSV-1 variant or with a secreted form of an engineered HSV-1 glycoprotein gB (gB-1s) and were subsequently challenged with a highly pathogenic HSV-1 variant. Immunization of rabbits with gB-1s was much more efficient than immunization with live virus in reducing the severity of herpetic keratitis and in preventing CNS disease.

Screening pregnant women for genital herpes

Neonatal herpes leads to serious morbidity and high mortality. The true incidence is unknown due to under reporting and difficulties in diagnosing the condition, but may be increasing. Mothers with primary disease, at term, present a greater infection risk to their offspring than mothers with recurrent disease, but the exact risks remain unknown. Existing prevention policies are inefficient, time-consuming for the doctor and the patient and, where caesarean section is offered to at-risk mothers, potentially hazardous. Anti-viral therapy offers a rational alternative and requires urgent evaluation.

Postinfection therapy of arbovirus infections in mice

Most antiviral agents are efficacious prophylactically in vivo, and a few are efficacious for postinfection (p.i.) therapy. To explore possibilities for p.i. therapy of encephalogenic Banzi virus (BZV) and Semliki Forest virus infections in mice, we evaluated candidate antiviral therapies after development of the first clinical signs of infection. The earliest clinical indication of BZV viremia in mice is a rise in core body temperature beginning on day 3 p.i. BZV-infected mice showing elevated core body temperatures (greater than or equal to 37.3 degrees C) on days 3 and 4 p.i. were treated intraperitoneally with the interferon inducer poly(ICLC) (80 micrograms per mouse) and/or specific antiserum. Combined therapy on day 3 of a BZV infection protected over 75% of mice showing clinical evidence of viral disease before treatment. Protection against early brain infection must occur on day 4 p.i., since by that day BZV has started multiplying in the brains of the mice. Significant protection occurred with antiserum alone and increased with poly(ICLC). Similar protection was obtained during Semliki Forest virus viremia, but this infection is so rapid that the first clinical signs are reliably detectable only after viremia.

Synergistic therapy by acyclovir and A1110U for mice orofacially infected with herpes simplex viruses

Clinical effects of the administration of a combination of acyclovir (ACV) and compound A1110U (a 2-acetylpyridine thiocarbonothiohydrazone inactivator of herpes simplex virus [HSV] ribonucleotide reductase) on the development of herpetic skin lesions were studied in athymic and hairless mice infected intracutaneously with different HSV type 1 (HSV-1) strains. ACV was administered topically (5%) or orally (5 mg/ml), while A1110U was applied topically (3%). In all but one experiment, the effect of combination therapy was greater than that calculated for the sum of the individual drug effects in limiting the development of herpetic skin lesions in mice. In several experiments, combination therapy totally eliminated all signs of infection. This synergistic chemotherapeutic efficacy was evident in infections caused by ACV-susceptible as well as several ACV-resistant HSV-1 strains. These results indicate that this combination therapy may provide a significant improvement in clinical responses over single-agent topical therapy.

Rapid identification and typing of herpes simplex virus by a new enzyme immunoassay with peroxidase-labeled complement C1q

A new enzyme-linked immunoassay system (TC-ELISA) was developed for the rapid, specific detection and typing of herpes simplex virus (HSV) using anti-HSV immune sera and enzyme-labeled complement component C1q (P*-C1q). The method is based on viral antigen produced in HSV-infected cells being detected by simultaneous addition of immune serum and P*-C1q (ELISA-CF). With this assay, it was found that HSV was detected with anti-HSV immune serum and P*-C1q and that HSV type 1 and HSV type 2 could be differentiated with anti-HSV-1 and anti-HSV-2 immune sera and P*-C1q. The TC-ELISA test was HSV specific and not reactive with measles virus, cytomegalovirus, mumps virus or varicella-zoster virus. The whole assay procedure can be completed within 3 hours, as long as HSV-inoculated cell cultures with more than 10% cytopathic effect are used. These results suggest that TC-ELISA is useful in the diagnosis of viral infections.

Intravenous acyclovir therapy of first episodes of genital herpes: a multicenter double-blind, placebo-controlled trial

PURPOSE

A collaborative multicenter double-blind, placebo-controlled trial of intravenous acyclovir treatment of first-episode genital herpes was performed in order to substantiate previous findings on the efficacy and safety of this drug, to evaluate the influence of parenteral therapy on recurrence frequency, and to obtain further data on the natural history of genital herpes.

PATIENTS AND METHODS

Eighty-two patients with first episodes of genital herpes simplex virus (HSV) infection were randomly assigned in a double-blind fashion to treatment with intravenous acyclovir (5 mg/kg every eight hours) or placebo for five days. Before therapy, all lesions in the genital/perineal area and in extragenital sites were cultured. New lesions appearing in both areas after the onset of therapy were cultured separately. Lesions in all groups were cultured until completely healed. Sera were collected from all patients on entry to the study and on Day 21 to determine presence or absence of antibodies to HSV-1 and HSV-2. Time to healing, time to crusting, time to cessation of viral shedding, and appearance of new lesions during therapy were compared for each treatment group.

RESULTS

Patients receiving acyclovir experienced a significant reduction in the median duration of pain (4.3 versus 4.8 days, p = 0.019), viral shedding (1.9 versus 8.4 days, p less than 0.001), and time to healing (8.4 versus 11.5 days, p = 0.02) compared with placebo recipients. These differences were largely attributable to the effect of therapy in the subset of patients with primary disease in whom acyclovir reduced the median duration of pain from 10.6 days to 4.2 days, the median duration of viral shedding from 17.1 days to 1.9 days, and the median time to healing from 14.2 days to 8.3 days. The rate of subsequent recurrence of genital herpes was not altered by acyclovir treatment: 24 of 32 acyclovir recipients (75 percent) experienced one or more recurrences during a mean follow-up of 14 months compared with 19 of 27 placebo recipients (70 percent). Among patients experiencing recurrences, the mean number of recurrences per month among acyclovir recipients was 0.25 compared with 0.19 for patients given placebo.

CONCLUSION

This multicenter trial confirms the efficacy of intravenous acyclovir in the management of first-episode genital herpes, especially in patients with primary infection. However, therapy did not alter the frequency of recurrences.

Dosage and safety of long-term suppressive acyclovir therapy for recurrent genital herpes

131 patients with frequently recurring genital herpes were treated for 1 year with reducing doses of oral acyclovir. The time to first recurrence in patients who commenced therapy on 400 mg twice a day was statistically significantly shorter than those on 200 mg four times a day (p less than 0.02) and as the total daily dose and frequency of therapy were lowered so the time to first recurrence was shortened. By the end of 60 days on 200 mg once a day (the lowest daily dose) 56% of patients had recurrences. Patients showed a marked reduction in the frequency of recurrence during therapy (from a mean of 1.1 per 28 days before to 0.11 during treatment, p = 0.0001). After stopping treatment the frequency of recurrences (0.71 per 28 days) was significantly less than the pre-treatment period (p = 0.001). No important side-effects were seen. It is concluded that long-term suppression with acyclovir is safe and effective for patients with recurrent genital herpes.

Treatment of first-attack genital herpes--acyclovir versus inosine pranobex

77 patients with a first attack of genital herpes were entered into a double-blind trial to compare the efficacy of acyclovir with that of inosine pranobex. 24 patients received acyclovir with that of inosine pranobex, and 28 both drugs. Patients treated with acyclovir or both drugs healed more quickly and had a shorter duration of viral shedding than those treated with inosine pranobex. The time to first recurrence and frequency of subsequent recurrences were similar in the three treatment groups. Acyclovir is the treatment of choice for patients with a first attack of genital herpes.

Acyclovir prophylaxis for herpes simplex virus infection

ACV is an effective agent for the treatment and prophylaxis of HSV infections in both IC and immunologically normal individuals. The drug is well tolerated in both populations and is not significantly associated with clinical or laboratory toxicities. Because of the great potential benefit and low risk, organ transplant recipients and patients with hematologic malignancies undergoing induction chemotherapy should be screened routinely for HSV antibodies; seropositive individuals should receive prophylactic ACV during the period of most profound immunosuppression. Immunologically normal individuals with frequently recurring genital HSV or serious complications associated with outbreaks are candidates for long-term suppression with ACV.

Treatment of recurrent genital herpes with topical alpha interferon gel combined with nonoxynol 9

A double-blind, placebo-controlled study was done to evaluate the efficacy of an alpha interferon preparation in 128 patients with recurrent genital herpes. The preparation containing 10(5) or 10(7) U alpha interferon with nonoxynol 9 in a cream base (Exovir-HZ) was applied three times daily for 5 days. The treatment did not cause any adverse reactions. Patients treated with either interferon concentration became negative for viral culture at a faster rate than placebo recipients. The end of new lesion formation, scabbing, and the healing of lesions were all superior in patients treated with 10(5) U to those treated with 10(7) U interferon. End of new lesion formation and scabbing were also statistically different in patients treated with 10(7) U from those patients treated with placebo. Results suggest that topical interferon might be useful in relieving symptoms of severe cases of genital herpes.

Xylotubercidin against herpes simplex virus type 2 in mice

Of a series of newly synthesized derivatives of the pyrrolo[2,3-d]pyrimidine nucleosides tubercidin, toyocamycin, and sangivamycin, the xylosyl analog of tubercidin, xylotubercidin, exhibited the greatest potency and selectivity against herpes simplex virus type 2 (HSV-2) in vitro. At dosage regimens that were not toxic for the host, xylotubercidin proved efficacious in various HSV-2 animal model infections. When applied topically at 0.25, 0.5, or 1% in dimethyl sulfoxide or when administered systemically (intraperitoneally) at 12.5 or 25 mg/kg per day, xylotubercidin suppressed the development of herpetic skin lesions and the paralysis and mortality associated therewith in hairless mice inoculated intracutaneously with HSV-2. In this model, acyclovir was effective only if administered topically at 5 or 10% in dimethyl sulfoxide. When administered intraperitoneally over a dosage range of 10 to 50 mg/kg per day, xylotubercidin achieved a significant reduction in the mortality rate of mice infected intraperitoneally with HSV-2. Under the same conditions, acyclovir did not offer any protection even when administered at doses up to 250 mg/kg per day. Xylotubercidin thus appears to have considerable potential for both topical and systemic treatment of HSV-2 infections.

Efficacy of combined treatment with oral and topical acyclovir in first episode genital herpes

Fifty patients presenting with first episode genital herpes were randomly allocated to seven day treatment with either oral acyclovir plus 5% acyclovir cream or oral acyclovir plus matching placebo cream. Combined treatment with oral and topical acyclovir was associated with a shorter duration of itching in women alone (p = 0.04) but gave no clinical relief of other symptoms, the time to healing of lesions, or the subsequent recurrence rate. Concomitant topical treatment with 5% acyclovir cream confers no advantages on patients who receive oral acyclovir.

Diagnosis and treatment of infection in cardiac transplant patients

Despite major advances in the management of rejection and the development of newer and more potent antimicrobials, infection still constitutes a major problem in transplant patients and other immunosuppressed hosts. Infectious complications in transplant patients clearly occur in two phases. The first phase includes the first 30 to 60 days after transplantation. During this period, nosocomial bacterial infections are most commonly encountered. Pulmonary, renal, and wound infections have all been encountered, and prophylactic antibiotics appear to decrease their frequency. Opportunistic infections usually do not occur during this period unless the patient undergoes treatment for acute rejection. The second phase of infectious complications usually follows the first month after transplantation. In this period, the level of immunosuppression is high, and opportunistic infections are common. Opportunistic pulmonary infections caused by P. carinii, L. pneumophila, cytomegalovirus, Aspergillus, and Nocardia spp. all are potentially life-threatening complications to the transplant patient. Aggressive diagnostic tests such as bronchoscopy, percutaneous needle biopsy, or open lung biopsy are frequently needed to make a diagnosis. Empiric broad-spectrum antimicrobial therapy is indicated in the ill patient; however, more specific therapy should be instituted once the diagnosis is confirmed.

Acyclovir in first attacks of genital herpes and prevention of recurrences

Sixty women patients experiencing a first attack of genital herpes were randomly treated with either oral acyclovir for 42 days or oral acyclovir for five days followed by placebo for 37 days. The median time to the first recurrence in patients receiving acyclovir for 42 days was 66.5 days compared with 24 days in those who received acyclovir for only five days (p less than 0.0001). This significant difference, however, was only observed for the treatment period. The frequency of recurrences was also reduced during the period of treatment in those who received prolonged treatment. During the subsequent follow up period, however, patients in both groups had a similar frequency of recurrences. Patients with infections due to herpes simplex virus type I (HSV I) had a significantly longer time to the first recurrence (p less than 0.001) and fewer recurrences (p less than 0.001) than those infected with HSV II, irrespective of treatment.

Efficacy of oral treatment with acyclovir and co-trimoxazole in first episode genital herpes

Forty patients presenting with first episode genital herpes were randomly allocated to seven day treatment with oral acyclovir alone, placebo alone, oral acyclovir plus co-trimoxazole, or placebo plus co-trimoxazole. Patients receiving acyclovir had significantly shorter periods of viral shedding (p less than 0.001), pain (p = 0.03), and times to lesion healing (p less than 0.05). Averaged over all patients there was no evidence that co-trimoxazole affected any of the variables, though in women cotrimoxazole was associated with a shorter time to lesion healing (p less than 0.01). Furthermore, the combination treatment gave significantly shorter times to lesion healing than acyclovir alone, placebo alone, or placebo and co-trimoxazole (p = 0.01) and good trends elsewhere (external lesions and duration of pain). Neither drug was associated with any adverse events or toxicity or influenced the subsequent recurrence rate.

Acyclovir prophylaxis of recurrent genital herpes: randomised placebo controlled crossover study

Forty patients were entered into a randomised placebo controlled crossover study to assess the efficacy and safety of oral acyclovir 200 mg four times a day in the prophylaxis of recurrent genital herpes. Each treatment began during a recurrence and continued for a maximum of 84 days or until the onset of the next recurrence, when the alternate medication was started. Of 28 patients who completed both treatment courses, only three developed a recurrence while taking acyclovir compared with 26 while taking placebo. The mean time to first recurrence was more than 84 days in patients receiving acyclovir and 24 days in patients receiving placebo (p less than 0.001). The mean time to first recurrence after treatment with acyclovir ceased was 16 days. Adverse events, though thought unlikely to be related to treatment, necessitated the withdrawal from the study of two patients while taking acyclovir and one patient while taking placebo. No clinically important effects on haematological or biochemical variables occurred during the acyclovir treatment. All viral isolates tested after treatment remained sensitive to acyclovir. Acyclovir prophylaxis of recurrent genital herpes is effective and safe but does not appear to influence the natural history of the disease after cessation of 84 days' continuous treatment.

Cutaneous adverse reactions to acyclovir: case reports

Intravenous, oral, and topical formulations of acyclovir have been successful in treating genital herpes. We report on two patients who developed skin reactions while taking acyclovir, which resolved when treatment was stopped.

Genital herpes: an increasing problem?

Over the past 10 years there has been a pronounced increase in the number of cases of genital herpes seen in sexually transmitted disease (STD) clinics in the United Kingdom. The reporting system, however, does not differentiate between primary and recurrent infections, and consequently any increase in the number of patients reattending clinics with recurrent genital herpes would falsely inflate the statistics. A study of cases of herpes seen in the department of genitourinary medicine of this hospital in the two years 1972 and 1982 is presented. It showed that the proportion of patients attending with recurrent herpes had increased from 18% in 1972 to 31% in 1982. As a result of this, the 68% increase between 1972 and 1982 in the total number of cases of herpes seen in the clinic overestimates the real increase in the size of the problem, which is closer to 40%, based upon cases of primary herpes only. Modifications to the national recording system are necessary to overcome the problems highlighted by this study. These modifications could include classifying each case of genital herpes as primary, recurrent, or recurrent but not previously recorded, which would provide a more accurate picture of the size of the problem of genital herpes in the population.

Treatment of chronic non-A, non-B hepatitis wih acyclovir: pilot study

Five patients with chronic non-A, non-B hepatitis were entered into a pilot therapeutic study of the antiviral agent acyclovir [9-(2-hydroxyethoxymethyl)guanine]. Each patient received acyclovir by slow intravenous infusion in a dosage of 5 mg/kg every 8 hr for 10 days. During therapy, serum aminotransferase levels decreased by more than 50% in two patients, remained unchanged in two patients, and rose (by 32%) in the final patient. The two patients whose serum aminotransferase levels decreased during acyclovir treatment subsequently received a second course of drug using a higher dose (10 mg/kg every 8 hr for 10 days). Serum aminotransferase levels rose in both patients (by 54% and 121%) during the second course of therapy. Acyclovir was well tolerated in these patients, and there were no symptoms or signs attributable to drug toxicity during or after treatment. During a subsequent 12-month follow-up period, none of the five patients has manifested either a clinical or serum biochemical improvement in their chronic liver disease. Spontaneous fluctuations in serum aminotransferase levels unrelated to acyclovir therapy were noted in three of the five patients. These findings suggest that a short course of acyclovir does not have any appreciable long-term beneficial effect on the course of chronic non-A, non-B hepatitis.